International Journal of Advances in Psychology Vol. 1 Iss. 3, November 2012
The Impact of Family on Obsessive
Compulsive Disorder in Children and
Adolescents: Development, Maintenance, and
Family Psychological Treatment
Martina Smorti
Faculty of Education, Free University of Bolzano, Bressanone, Italy
Email: martina.smorti@unibz.it
Abstract
It is widely recognized that some parental characteristics
can influence obsessive compulsive disorders in children
and adolescents. Family involvement and parental style
characterized by high expressed emotion, over-protection,
over-control are associated with the development of
obsessive compulsive disorders in children. As a
consequence, family involvement in the treatment of youth
with obsessive compulsive disorders has been widely
suggested. Although various forms of family therapy are
used, cognitive behavioural treatment is widely recognized
as the first-line treatment of paediatric obsessive compulsive
disorders. Despite several studies reveal efficacy of family
therapy, it has been underlined that more than an half of
children remain symptomatic post-treatment. In order to
improve treatments for children with obsessive compulsive
disorders, research has identified personal and familiar
predictors of response to treatment. The clinical implications
of these studies are discussed.
Keywords
Obsessive Compulsive Disorder; Childhood; Adolescence; Family;
Psychological Treatment
Introduction
Obsessive-compulsive disorder (OCD) is an anxiety
disorder that involves (a) intrusive, unwanted thoughts,
ideas, or images that evoke anxiety (obsessions), and (b)
deliberate behavioural or mental rituals, that serve to
neutralise anxiety (compulsions) [1]. OCD affects as
many as 2-3% of children [2, 3] with significant
functional impairment in a number of critical domains.
The obsessions and compulsions that characterise OCD
interfere with social, academic, and family
environments [4-5] and have negative consequences on
quality of life [6].
Common obsessions in children have themes of
contamination, aggression (harm or death), symmetry,
and exactness, while in adolescence, religious and
sexual obsessions also become common [7]. Common
compulsive behaviours reported in young people
include hand washing/cleaning, counting, praying, and
checking [8].
The literature review and discussion in this article
focuses on the role that parents and family members
have on OCD in childhood and adolescence.
Family-based treatments for young people with OCD
will be also reviewed and their efficacy will be
discussed.
Family Factors Associated With Childhood
Ocd
Family involvement
Several authors place great importance on the role of
the family environment in the development and
maintenance of OCD [9]. This emphasis is logical
because the vast majority of children and adolescents
spend a significant portion of their lives in the
presence of families. In this context, it has been
suggested that family members of youth with OCD
are often involved in the young person's rituals
[10-12]. The person's obsessive doubts,
indecisiveness, constant search for reassurance, and
avoidance behaviours can lead to extreme
dependence on family members, who usually have to
assume many of the person's activities, duties, and
responsibilities [13]. Family participation in the
child's obsessive-compulsive symptoms is referred to
as "family involvement" or "family accommodation"
[10]. Family participation can operate both directly
(e.g., participation in rituals; interference with or
intrusion in rituals) and indirectly (e.g., modification
of the family's lifestyle around the symptoms). Some
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International Journal of Advances in Psychology Vol. 1 Iss. 3, November 2012
authors have attempted to describe familiar
responses to obsessive-compulsive symptoms along
a continuum ranging from accommodating to
antagonizing [14]. An accommodating response
refers to that of those families whose members are
consistently involved in, and supportive of, their
child's rituals [15]. The goal of such involvement is
often to help the person with OCD to reduce distress
[16]. An antagonistic response instead refers to that
of families who are critical and hostile towards the
child's symptoms and who consistently refuse to
encourage or be involved in the ritualistic behaviour.
Attempting to stop the child from performing his or
her ritual and forced traumatic exposure to the
feared stimulus are examples of antagonistic family
involvement [14]. Of course there are also situations
where one parent takes the antagonizing stance and
the other is accommodating of the symptoms. Even if
this is a rather simplistic categorization of familial
responses, one point is clear: regardless of whether
families reject or accommodate the symptoms, they
are often inextricably involved in the disorder.
Moreover, both accommodating and antagonizing
family responses tend to perpetuate and reinforce
OCD symptoms, increasing the frequency and/or
severity of the rituals [16-17].
Parenting style
It is widely recognized that some characteristics of the
family environment are associated with the
development of OCD in children. One family factor
that has been associated with OCD is expressed
emotion [18-21]. Expressed emotion refers to a family
environment characterised by hostility, criticism, or
emotional over-involvement [22]. It has been found
that high expressed emotion is characteristic of
families with an OCD child in comparison to families
with a typically-functioning child [20]. Moreover, high
expressed emotion is also associated with child OCD
symptom severity [21] and greater family
accommodation. Moreover, parental attitudes
characterized by over-protection, over-control [23],
low confidence in the child's ability, low reward of
independence [18], parental blame [24], low
problem-solving skills, and high parental
catastrophising behaviour [18-19] are associated with
OCD in children. On the other hand, low affection [23]
and low support [25] have been found in parents of
youth with OCD. These parental attitudes may create
avoidance, caution, and tearfulness in children and
thus predispose them to developing obsessive-
compulsive symptoms [26]. Moreover, factors such as
high parental anxiety [27] and perceived lack of
control over external events [28] are also hypothesised
to be relevant to the exacerbation of OCD in
childhood.
Psychological Treatments: The Role Of
Family
Consistent with previous considerations, family
involvement in the treatment of children with OCD
has been widely suggested [29-31]. In fact, children
need significant family support in order to address
OCD symptoms and parents need specific tools (e.g.
behaviour modification strategies) to help their
children to implement the treatment program at
home [32]. Moreover, since high levels of hostility
and criticism (expressed emotion) have been
associated with child OCD symptom severity and
greater family accommodation [21], involving
parents in child OCD treatments is important for
three reasons.
First, because hostility and criticism could result
from parents' believe that children with OCD could
control their compulsions [33] and that they tend to
be manipulative with their obsessions and
compulsions [34], a family intervention could be
useful for parents to understand their children's
problem. Thus, explaining the genesis of the
behaviors, delineating the boundaries of the disorder
and attributing mental health symptoms to the
illness (external attribution) rather than to the patient
(internal attribution) may help parents have a more
positive attitude toward OCD symptoms [34] and to
moderate high expressed emotion [35]. Second,
including parents directly addresses parents'
tendency to accommodate their child's OCD
behaviour [36]. Third, training parents to be coaches
for their children plays a key role in shaping
treatment and ensures adherence and motivation
outside of the treatment session [36].
Various forms of family therapy are used in the
treatment of paediatric OCD. Most interventions
adopt behavioural therapy, involving exposure to
feared situations and the prevention of compulsive
behaviour [37], cognitive therapy, in which intrusive
thoughts are identified, understood and discussed
[38-41], and a combination of behavioural and
cognitive therapy [42-44].
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Cognitive-behavioural family therapy for young
people with OCD is based on the recognition that
families are so involved in the young person's rituals
that family relationships are disrupted. Consistent
with several works, cognitive-behavioural family
treatment involves the parents, the child and the
therapist [45-46]. The focus of the treatment is to help
the family understand how their involvement can
maintain the disorder and then help them withdraw
from the compulsions. Although the aim of
cognitive-behavioural family therapy is to improve
family relationships, the focus is more on reducing
the affected individual's obsessive-compulsive
symptoms [47].
Few treatment interventions have adopted systemic
family therapy approaches for paediatric OCD cases.
General systems theory assumes that living
organisms can be seen as a group of elements in
interaction with one another, forming stability over
time, with boundaries within itself and between itself
and the environment. The system has properties such
as wholeness and non-summativity (the whole is
greater than the sum of its parts), feedback
incorporated to maintain the function of the system
(homeostasis), and equifinality (the same endpoints
can be reached by different stimuli (the organisation
of the system is more significant in determining
reactions) [48].
In OCD treatment, systemic family therapy tends to
focus on the meaning of the symptoms within the
family unit. In this approach, family treatment
involves the parents, the OCD child, siblings and the
therapist [49]. The therapist tends to see OCD
symptoms as a sign that the family unit is stressed,
leading to difficult, unspoken emotions between
family members [47]. These interventions aim at
altering the family system, improving relationships,
and increasing communication and emotional
expression amongst family members. While these
family interventions have included procedures
designed to alter family dynamics directly [50-51],
they have often also included behavioural
components [51-52]. Other interventions have
adopted systemic family therapy approaches where
OCD has been considered to represent a metaphor
for family dysfunction [51-52].
Techniques used in family therapy for OCD children
Cognitive behavioural therapy is widely recognized
as the first-line treatment for young people with
OCD [31, 53-55].
It has been suggested that involving family in
cognitive behavioural therapy allows children to
enter anxiety-provoking situations in a planned way
and to manage these through the use of coping skills
and parental support [56].
1) In cognitive-behavioural family therapy both
parents and children attend separate group sessions
and some concurrent family therapy sessions [57].
Cognitive-behavioural family therapy offered to
individuals or groups has been found to be equally
effective [31]. The main components of cognitive-
behavioural family therapy are:
2) Psychoeducation. This typically includes
discussion of the nature of the disorder, its causes,
prevalence, prognosis, maintenance factors, and
effective treatments for it. It is important "to
externalise the problem", clarifying to both family
and the person with the disorder that OCD is a
medical illness which is distinct from the youngster's
core identity [58]. Externalising OCD in this way
helps the child and family to feel empowered and to
decrease anxiety [59] and assists parents to reduce
hostile attitudes toward their child. It has been found
that relatives who believed that people with OCD
could control their compulsions were likely to be
more hostile and critical than those who considered
the OCD symptoms to be an illness [33].
Psychoeducation also aims to clarify that both the
child and family already have some influence over
this disorder [58]. So the therapist, child, and family
become members of the same team with a unified
goal of helping the child eliminate OCD from his or
her life [58].
3) Parenting tools. Parents are provided with a set of
tools used throughout treatment to increase the
child's motivation for change and to more effectively
manage their child's OCD symptoms. The main
parenting tools include differential attention,
modeling, and scaffolding [60]. For differential
attention the therapist explains to the parents that
they can use their attention to change their child's
behaviour. So, they can give attention to behaviour
they want to see and withhold attention from the
behaviour they do not want to see [32]. For the
modeling, the therapist explains how parents can
positively reinforce the child's behaviour by giving
positive attention and tangible rewards [60]. For the
scaffolding, the therapist explains how parents can
guide their child's emotion regulation in response to
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an event so that the child internalises his or her
response through self-regulation [32].
3) Exposure and response prevention. This is directed at
the young person with OCD and aims to get parents
and children to actively work together. This
treatment has been designed to expose the individual
to provocative stimuli (e.g., touching a
"contaminated" object) while simultaneously
refraining from compulsions (e.g., hand washing) [29]
and it has been found to be an effective treatment for
children with OCD [4, 61]. In exposure and response
prevention, firstly a hierarchy of symptoms is created.
A hierarchy of rituals can be constructed which
includes a rating for the degree of anxiety
experienced by the youth when he or she refrains
from carrying them out. The gradual nature of this
approach allows the child or adolescent to increase
his or her anxiety management skills [62].
4) Homework. This is given to the person with OCD at
each treatment session. Tasks to perform at home
relate to one or more of the items on the hierarchy,
and usually begin with the lowest rated item. The
purpose of this homework is for the child with OCD
to practise mastery over the symptoms. The therapist
must explain these homework assignments carefully
to the child, emphasizing the importance of mastery
over OCD each and every day [63] . In family therapy
parents are asked to tolerate their own distress while
they assist their children during upsetting exposure
exercises and homework tasks [36]. Parents are also
asked to monitor their child's behaviour and to
encourage self-exposure in a noncritical manner [64].
For example, if a child washes his or her hands
several times per day, reducing the number of
handwashings per day could be part of a homework
assignment. Parents must then support the child in
postponing his or her handwashing and at the same
time, they must increase the length of the
compulsion- free intervals [63].
5) Anxiety management training. For children with
predominantly internalising symptoms, treatment
often includes anxiety management training. This
therapeutic "tool", which includes progressive
muscle relaxation, diaphragmatic breathing, and
coping imagery [65], allows the child to better
manage the changes in affect that occur before,
during, and after exposure and response prevention
[66]. In family intervention, anxiety management
training involves teaching parenting skills for
managing child distress and avoidance, parenting
skills for parents to manage their own anxiety, and
parental communication and problem-solving skills
[67].
While engaging family members in OCD treatment
for young people has been broadly suggested as
being important, only a few interventions pay
particular attention to family accommodation [68-69].
In these interventions, antagonistic or
accommodating behaviours were firstly identified
and discussed. Then, if a family member was
assessed as being too accommodating, that
individual received homework assignments related
to reducing the accommodation, such as working
with the young person to come up with a plan to
begin disengaging from help during a compulsion. In
the case of an antagonizing family member, he or she
received training in methods to disengage from the
conflict [68-69].
Several studies have been conducted to evaluate the
efficacy of cognitive-behavioural family therapy.
These investigations have revealed that family
therapy significantly decreases symptom severity, as
well as symptom-related distress and impairment,
and treatment gains have been maintained over time
[31, 44, 53, 69]. However, despite its effectiveness,
treatment response is less than perfect, with a
substantial percentage (more than fifty per cent) of
treatment recipients remaining symptomatic
post- treatment [30].
Predictors Of Ocd Treatment Outcome
In order to improve treatments for children with OCD,
several studies have tried to identify predictors of
treatment response in paediatric OCD or, in contrast,
predictors of non response to treatment [70-71].
Recently, two interesting literature reviews focused on
predictors of treatment response in young people with
OCD [70-71]. Results suggested that parental high
expressed emotion, hostile criticism, and emotional
over-involvement [72-73] are associated with greater
dropout and/or poor cognitive behavioural treatment
outcome for people with OCD.
With regard to expressed emotion, it has been
suggested that parents' criticism does not appear to be
problematic if it is not hostile. In fact, while criticism
of OCD behaviours may serve as a motivator for
people to seek therapy and work on their problem
during treatment, hostile criticism appears to make it
difficult for them to continue in treatment and to
benefit from it [74].
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Other studies have reported that high family
accommodation was associated with a worse response
to behavioural therapy in children with OCD [68, 74].
In addition, decreases in family accommodation
during treatment predicted treatment outcome:
helping family members disengage from compulsions
and resist accommodation during behavioural
therapy appeared to improve OCD treatment
outcomes [68-69].
It has also been highlighted that greater obsessive
compulsive symptom severity [70-71] and a comorbid
diagnosis of a personality disorder [71] consistently
predict poorer treatment responses for these
individuals.
Finally it has been displayed that the therapeutic
alliance is a reliable predictors of treatment response:
both child-therapist and parent-therapist therapeutic
alliance, indeed, have been indicated as significant
predictor of subsequent change in OCD symptoms
treatment outcome [75].
Conclusions
The studies on OCD in young patients in the present
review indicate the reinforcing role of both expressed
emotion [18, 74], that is a parental attitude
characterised by hostility and criticism [22], and
family involvement in the individual's rituals, either
in an accommodating or antagonizing manner [10, 11,
14].
Given the central role of family in the development
and maintenance of OCD in children and adolescents,
including family members in the young person's
therapy may be advantageous in order to educate and
advise parents about OCD symptoms and how to
respond to their child [29- 31]. Moreover, training
parents to be coaches for their children plays a key
role in shaping treatment and ensures children's
adherence to treatment and motivation outside of the
treatment session [36].
Several family-based treatments have been proposed
for children with OCD. Most of these interventions
have adopted cognitive-behavioural family therapy
[42-43] while a few of these have used systemic family
therapy [50-51].
Although most studies on OCD treatments emphasise
improvements in young people's symptoms [31, 53,
69], some of them point out methodological flaws in
these interventions and these reveal that treatment
efficacy is less than perfect with more than an half of
children remaining symptomatic post-intervention
[30].
All these concerns suggest to redefine our
methodological approach to family therapy
identifying the best method to achieve the greatest
efficacy. The first issue concern therapy orientation.
As previous mentioned, cognitive behavioural
therapy, as the first-line of treatment for OCD
paediatric patients, it is well structured and wide
adopted. However, although the focus of the
treatment is to the family, it usually involves the
parents, the child and the therapist but not siblings
[45-46]. On the other hand systemic therapy involves
parents, paediatric patient, siblings and the therapist
[49] but it has been less used in OCD treatment. Thus,
it could be useful adopt cognitive behavioural family
therapy as the first line of treatment but including
siblings as suggested by Barrett [31].
The second issue concerns family factors that should
be taken into consideration and managed in planning
a family intervention for children with OCD. In this
context studies on predictors of treatment response in
young people with OCD are crucial [70-71].
Parental high expressed emotion, hostile criticism,
and emotional overinvolvement [72-73] should be
considered as predictors of treatment dropout. For
this reason Steketee and colleagues [22] have
suggested assessment and intervention strategies for
reducing criticism and hostility during psychological
treatment. Thornicroft, Colson and Marks [64]
reported a treatment program where relatives were
asked to monitor their child's behaviour and to
encourage his or her self-exposure in a noncritical
environment. In this context, "externalising the
problem" during the psychoeducational treatment
component helps parents to become less hostile and
critical toward the young person with OCD [33].
Another relevant family factor to take into
consideration is family accommodation [68, 74]. As
was previously mentioned, some strategies could be
useful for managing family accommodation in
family-based interventions for OCD young cases.
Some of these are specifically focused on family
accommodation [68-69], others have been designed to
alter family dynamics [50-51], while others, moving
from family-based treatment, can help parents to
avoid inadvertent reinforcement of children's
compulsive rituals [56].
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Lastly the timing of the treatment seems to be another
crucial variable. The findings from previous studies
have indicated that symptom severity and the
presence of a comorbid personality disorder should be
taken into consideration in planning OCD treatment
[70-71]. These data emphasize the importance of
treating OCD as soon as possible. In fact, if left
untreated, or if inadequately treated, there is an
increased likelihood that the OCD in these young
children will extend into their adulthood [60], thereby
enhancing the severity of their obsessive compulsive
symptoms [76]. Moreover, leaving OCD untreated
increases the risk of comorbidity in adulthood [77].
However, as Maskey [34] noted, despite the
considerable distress and disability accompanying
OCD, most parents do not recognize the nature of the
disorder. As such, it is often unrecognised and
undertreated. Family members need to be able to
recognise various presentations of OCD. To assist
with this, health promotion activities focused on OCD
could be carried out both in schools and at the public
health service. In this way family members could be
informed about OCD and refer their children and
adolescents to a specialist without delay.
Finally, in order to improve OCD interventions for
youth, more studies on predictors of OCD treatment
response are crucial since these can suggest factors
that should be taken into consideration in planning
interventions for children with OCD.
ACKNOWLEDGEMENTS
We would like to thank Sarah L. Barker for her review
of the English translation.
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Author Introduction
Martina Smorti is research Professor
of Developmental Psychology at the
Faculty of Education of the Free
University of Bozen. Her research
interests focus on adolescence, risk
behaviours and health psychology.
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